BlueChoice Opt-Out Open Access - Your Member Handbook

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CareFirst BlueChoice, Inc.
BlueChoice Opt-Out
Open Access
Your Member Handbook

FirstHelp ® Health Care Advice Line: (800) 535-9700
VA FORM #: BOK5075-1S (12/09) web only
BlueChoice Opt-Out
Thank you for choosing CareFirst BlueChoice, Inc.’s (CareFirst BlueChoice) BlueChoice Opt-Out
Plan. We are committed to providing our members and their families with the highest level of service
possible and hope that the information included in this handbook will assist you in understanding
your CareFirst BlueChoice beneﬁts and options.

Please take a moment to review this information and then keep it in a safe place for future reference.
This booklet, along with your Summary of Beneﬁts and enrollment materials, gives you tips on
how to receive the highest level of health care beneﬁts. This guide is meant to be an overview and
describes important features of BlueChoice Opt-Out. However, it is not a contract. A detailed
description of speciﬁc terms, as well as the conditions and limitations of your coverage, is included
in your Evidence of Coverage.

As always, please contact Member Services at the telephone number listed on the front of your
member identiﬁcation card if you have any questions regarding your coverage. We appreciate
your business and look forward to serving you in the future.

Keep in a safe place for future reference.

You may also view this handbook online at www.careﬁrst.com in the Members & Visitors section.

i
Important Information
Emergency Assistance and
Member Services Medical Advice
Please contact Member Services at the telephone In case of a medical emergency, call 911 or go to the
number listed on your member identiﬁcation emergency room. You should call your physician when
card. Our service hours are: you have a health problem. If you cannot reach your
physician and have questions about your health, an
Monday – Friday, 7:00 am – 7:00 pm EST illness or an urgent medical condition, FirstHelp®
Saturday, 8:00 am – 1:00 pm EST is available to help you make a decision concerning
the most appropriate level of care.
Multi-lingual translators are available for
assistance through Member Services. FirstHelp® Health Care Advice Line
(24 hours a day) Toll-free: (800) 535-9700
Contact Member Services for beneﬁt and
contract information. Hospital Authorization/Utilization
Management
When writing to CareFirst BlueChoice, always
include your Member Identiﬁcation Number. Your CareFirst BlueChoice provider should obtain
Please address your correspondence to: any necessary admission authorizations for covered
services. Toll-free: 866-PREAUTH (773-2884)
CareFirst BlueChoice, Inc.
P.O. Box 644 Mental Health/Substance Abuse Care
Owings Mills, MD 21117-9998 Call the telephone number on your identiﬁcation card
under the Mental Health/Substance Abuse Service and
Authorization section. Assistance is available 24 hours
Please refer to the Evidence of Coverage for speciﬁc terms, a day, 7 days a week.
conditions, limitations and exclusions.
Additional Telephone Numbers
Pharmacy Beneﬁts (Argus Health Systems)*
(800) 241-3371

Vision Beneﬁts (Davis Vision)*
(800) 783-5602

Away From Home Care®
(888) 452-6403

*Your coverage may not include these beneﬁts. Refer to
your Evidence of Coverage for details.

ii FirstHelp ® Health Care Advice Line: (800) 535-9700
Contents
Welcome to BlueChoice Opt-Out ......................................................................................... 1
Frequently Asked Questions .................................................................................................. 2
When You Need Care ............................................................................................................. 5
■ Your Primary Care Physician ■ Medical Records ■ Scheduling Appointments
■ Canceling Appointments ■ Laboratory Services ■ In-Network Beneﬁts

CareEssentials.......................................................................................................................... 8
■ Prevention ■ Vitality Newsletter ■ Get Healthy With My Care First
■ Great Beginnings Program for Expectant Mothers ■ Preventive Services Guidelines
■ Utilization Management ■ Hospital Care ■ Disease Management Programs ■ Case Management Program

Options Discount Program................................................................................................... 12
■ Discounts on Alternative Therapies and Wellness Services

Emergency and Urgent Care ................................................................................................ 15
■ Medical Emergencies ■ Urgent Care ■ FirstHelp® Medical Advice Line ■ Care When Traveling
■ BlueCard Program ■ Follow-Up Care ■ The Away From Home Care® Program

Seeing Mental Health Specialists ......................................................................................... 18
Additional Beneﬁts ............................................................................................................... 19
■ Dental Beneﬁts ■ Prescription Beneﬁts ■ Vision Beneﬁts

Administration of Your Plan................................................................................................ 22
■ Personal and Enrollment Changes ■ Filing a Claim for Reimbursement ■ Provider Reimbursement
■ Other Insurance ■ Member Satisfaction

Appeals Process ..................................................................................................................... 24
Your Coverage ....................................................................................................................... 25
■ Ending Your Coverage ■ Continuing Your Coverage ■ New Technology Assessment

Portability.............................................................................................................................. 26
Conﬁdentiality ...................................................................................................................... 27
■ Our Responsibilities ■ Notice of Privacy Practices ■ Your Rights

Member Rights and Responsibilities ................................................................................... 28
■ Rights of Members ■ Responsibilities of Members

Deﬁnition of Terms .............................................................................................................. 29
Index ...................................................................................................................................... 31

www.carefirst.com iii
Welcome to BlueChoice Opt-Out
BlueChoice Opt-Out offers the ﬂexibility The diagram below explains the information on
the front of your card. Please take a moment to
to receive care outside the HMO network. review your card. If any of the information is
With this product, care can be provided and incorrect, please contact our Member Services
Department immediately.
coordinated by a primary care physician
(PCP) when you select from the CareFirst
BlueChoice Network.
5
Your PCP provides preventive care and can help you
1 6 7
obtain specialty care. By helping to coordinate your 1
OPEN ACCESS
care, your PCP ensures quality of care while reducing
medical expenses. When your selected PCP provides 2 XIC000000000 0A01 3
or coordinates your care, you are using in-network 2
4 3 JANET DOE
beneﬁts. You also use in-network beneﬁts when you PCP NOT ON APPLICATION
5 4
see any other BlueChoice PCP or specialist. Unique 6 P5 S10 ER25 RX 7
to this plan is that you don’t need a PCP referral for
in- or out-of-network care. You may still need an
authorization from the plan for some services. This is a sample member ID card. Please review your actual
card for your ID number and information specific to your coverage.

Your BlueChoice Opt-Out Plan provides you with the
ability to see doctors outside of our network and still 1 MEMBER SERVICES TELEPHONE NUMBERS
have part of that care covered. If you choose to see a
2 MEMBERSHIP IDENTIFICATION NUMBER
non-CareFirst BlueChoice provider you are using your
out-of-network beneﬁts. You may need to pay for 3 GROUP NUMBER
the services at the time of the visit and ﬁle a claim
for reimbursement. You will be responsible for a 4 MEMBER’S NAME
percentage of the plan allowance and any provider
charges above that amount. 5 PRIMARY CARE PHYSICIAN’S (PCP) NAME

Your Membership Card 6 COPAYMENTS
By now you should have received your BlueChoice P= PCP
Opt-Out membership identiﬁcation card. Your ID S= SPECIALIST
card identiﬁes you as a CareFirst BlueChoice ER= EMERGENCY ROOM
member and contains important information about RX= PRESCRIPTION
you, your primary care physician (PCP), your
copayments and some of the beneﬁts for which you 7 DENTAL COVERAGE, IF APPLICABLE
are eligible. This is the card that you present to your
PCP, a specialist or a hospital to receive care. Always The back of the ID card includes medical emergency assistance
and mental health/substance abuse telephone numbers, as well
carry your membership card with you. (If you haven’t as instructions and an address for ﬁling claims and sending
received your card yet, please use your copy of the correspondence. If your ID card is lost or stolen, please contact
CareFirst BlueChoice enrollment form.) Member Services immediately for a replacement. Remember to
destroy any old cards and always present your current ID card
when receiving services.

1 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions
What is my ID card for? How do I know which specialists I can use?
Your card is important to getting the most out of Can I use any specialist listed in the CareFirst
your health plan. You will present your card when BlueChoice Provider Directory?
you receive care. Always carry your member ID You will receive the highest level of coverage
card with you. when you see an in-network specialist. You can
For more information, see the section “Your Membership check the Provider Directory on our web site at
Card” on page 1 of this handbook. www.careﬁrst.com, or contact Member Services
to verify if a specialist is in the CareFirst
How can I ﬁnd out if a certain doctor is BlueChoice network.
a primary care physician with CareFirst
BlueChoice? Can I change my primary care physician?
You can access our CareFirst BlueChoice Provider Yes, you can change your primary care physician.
Directory on our web site at www.careﬁrst.com. You Contact Member Services, and a representative will
can also call the Member Services telephone number assist you. CareFirst BlueChoice must be notiﬁed and
on the front of your identiﬁcation card to request a must process the PCP change prior to the time you
CareFirst BlueChoice Provider Directory or a Member receive care from the new PCP.
Services Representative can access this information For more information, see the section “Changing Your
for you. Primary Care Physician” on page 6 of this handbook.
For more information, see the section “Selecting Your
Primary Care Physician” on page 5 of this handbook. How can I ﬁnd out if I have a particular beneﬁt?
Your beneﬁts are detailed in the Evidence of Coverage.
How do I obtain specialty care? You may also contact Member Services to obtain
Your primary care physician (PCP) can help to speciﬁc information on contract beneﬁts such as
coordinate your in-network care. However, a PCP medical care, vision care, dental care, prescription
referral is not necessary for in- or out-of-network beneﬁts, etc.
care. You will pay less out-of-pocket by seeing an
in-network specialist. I will be traveling out of town. What coverage
do I have?
For more information, see the section “No Referrals
When you are outside of the service area, in-network
Needed for Specialists” on page 6 of this handbook.
beneﬁts are available for emergency or urgent care
Do I need a referral for specialists? only. When traveling, out-of-network beneﬁts are
available for other covered services. In addition, if
No, you do not need a written referral from your PCP you will be traveling for 90 days or more, you may
to seek care from a specialist. However, you or your be eligible for the Away From Home Care® Program.
provider may need to obtain an authorization from
the plan for some services, including but not limited For more information, see the sections “Emergency and
to hospital care. Urgent Care” on pages 15-18, “The Away From Home
Care® Program” on page 17 and “Filing a Claim for
Reimbursement” on page 22 of this handbook.

www.carefirst.com 2
Frequently Asked Questions

If I need in-area emergency care, Our Prevention tools are designed to help
what should I do? you stay strong and healthy.
If your situation is a medical emergency, call 911
or seek help immediately at the nearest emergency
or urgent care facility. In an urgent situation, we
recommend that you contact your PCP for advice. Utilization Management helps ensure you
If you are unable to reach your PCP, you may contact receive the right care at the right time in
FirstHelp®, our 24-Hour Emergency Assistance and the right place.
Medical Advice Service at (800) 535-9700.

For more information, see the “Emergency and Urgent Disease Management assists members with
Care” section on pages 15-18 of this handbook. chronic illnesses to make smart choices for
healthy living.
I have a dependent who will be going away to
college. What coverage does he or she have?
If the college is outside of the CareFirst BlueChoice Case Management provides support
service area, coverage is limited to emergency or to members when it is needed most.
urgent care only. For more information, see the
section “Emergency and Urgent Care” on pages 15-18
of this handbook. Students who will be out of the
Look for the CareEssentials logos in this member
area for 90 or more days may be eligible for the Away
handbook to learn more about how CareEssentials
From Home Care® Program.
can work for you.
For more information, see the “Away From Home Care®”
section on page 17 of this handbook. What can I do to ensure I pay the
lowest copay for my prescription?*
Where should I go for covered
laboratory services? To ensure that you are paying the lowest
copay for a prescription, you should check
Members must go to LabCorp® for any laboratory
the status of the drug on the CareFirst
services in order to obtain in-network coverage for
preferred drug list before:
those services. LabCorp® is contracted to provide
services for CareFirst BlueChoice members throughout ■ You talk with your doctor about a reﬁll
Maryland, Virginia and Washington, DC. or a change in your medication.
For more information, see the “Laboratory Services” ■ You call the pharmacy to order a reﬁll.
section on page 7 of this handbook.
■ You order a prescription through
What is CareEssentials? mail order.
CareEssentials is CareFirst BlueChoice’s Care
Management program that provides you with the
tools and resources that will help you stay healthy *This information applies only to members whose
or make you well. prescription drug program is based on the CareFirst
BlueChoice preferred drug list (also called a formulary).

3 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions

For example, if you check the status of your brand- What kind of information can I ﬁnd on
name drug and ﬁnd out there is a generic equivalent on “My Account”?
the CareFirst BlueChoice preferred drug list, we suggest
When you visit My Account on www.careﬁrst.com,
you talk with your doctor to see if a generic alternative
you can ﬁnd information about your medical plan
is the right choice for you.
including who and what is covered, claims status, and
For more information on how to cut prescription how much has been applied to your deductible if you
drug costs, see the “Prescription Drug” section on have one. In addition, our secure e-mail feature will
pages 19-20 of this handbook. enable you to send inquiries to us.

To use My Account:
1. Go to the Members & Visitors section of
What kind of information can I ﬁnd www.careﬁrst.com and click on the My Account
on www.careﬁrst.com? button on the left.
At www.careﬁrst.com you can:
2. Register using the membership number
■ Find out the latest member news located on your member ID card.
and updates.

■ Download claim forms and privacy forms.

■ Learn how to get discounts on alternative
therapies, vision and hearing services,
ﬁtness centers and more through the
Options discount program.

■ Find a doctor who participates in
your plan using our searchable
provider directory.

■ Look up health and wellness information
at My Care First.

■ Get Member Services phone numbers.

■ Read answers to more of your frequently
asked questions.

■ Find beneﬁt and eligibility information
on My Account.

■ Order a new member ID card on
My Account.

www.carefirst.com 4
When You Need Care
Your Primary Care Physician Selecting your primary care physician
When you joined CareFirst BlueChoice, you should You may choose a doctor who specializes in family
have chosen a primary care physician (PCP) to be practice, general practice, pediatrics, or internal
responsible for your primary medical care. If you did medicine as your PCP. Each member must choose
not choose a PCP upon enrollment, please contact a PCP from our CareFirst BlueChoice Provider
Member Services. The name of the PCP currently Directory at the time of enrollment. Your entire
on ﬁle for you appears on the front of your CareFirst family may select the same doctor, or each member
BlueChoice ID card. may choose a different doctor based on each
individual’s age or medical needs.
Establishing a relationship with one doctor is the best
way for you to receive consistent, quality health care. You may select your PCP by reviewing our list of
We encourage you to contact your PCP for an initial participating PCPs in the CareFirst BlueChoice
health assessment within 90 days of your enrollment. Provider Directory, by visiting our web site,
If you have any questions about scheduling your www.careﬁrst.com, or by contacting Member
appointment, please call your PCP’s ofﬁce. Services. Our staff is ready to assist you in selecting
a physician, and we can provide you with information
about a doctor’s background and hospital afﬁliation.
You can obtain speciﬁc information about a
We encourage you to ﬁnd a physician whom physician’s practice style and ofﬁce hours directly
you feel comfortable with and schedule all from the physician’s ofﬁce.
of your appointments with him or her.

Your PCP will:

■ provide basic medical care – treating
illnesses and providing preventive care;

■ prescribe any medications you may require;

■ maintain your medical history; and

■ work with you to determine when you
should see a specialist, and assist in the
selection of a specialist.

5 FirstHelp ® Health Care Advice Line: (800) 535-9700
When You Need Care

Changing your primary care physician Scheduling appointments
If you wish to change your PCP, contact Member CareFirst BlueChoice physicians see patients in their
Services and give the representative the name of the own ofﬁces. Always call for an appointment before
PCP to whom you want to switch. If the change is visiting your physician and identify yourself as a
requested prior to the 20th of the current month, it CareFirst BlueChoice member. Don’t forget to bring
will be effective on the ﬁrst of the following month. your member ID card to your appointment and
Requests received after the 20th of the current month present the card to the receptionist. You should
will be effective on the ﬁrst of the second month always present your CareFirst BlueChoice member
following your request. For example, a request received ID card whenever you seek care at your PCP’s or
on January 21 would be effective March 1. You will specialist’s ofﬁce or the hospital.
receive a new identiﬁcation card with your new PCP’s
name. Please destroy your old member ID card once CareFirst BlueChoice has set goals for providers in
the change becomes effective. our participating network regarding appointment
availability and ofﬁce waiting times. For appointments
No referrals needed for specialists for non-symptomatic visits, such as preventive care or
Your PCP can coordinate your medical care and routine wellness, we expect the doctor to schedule the
provide treatment for a variety of medical conditions. appointment within four weeks.
You can also go directly to a specialist from those
listed by specialty type in your CareFirst BlueChoice If you have an urgent problem, call your PCP as
Provider Directory. If a provider with the required soon as possible, and the ofﬁce staff will arrange an
specialty is not available within the CareFirst appropriate time for you to be seen. For a
BlueChoice network, your PCP should contact symptomatic (acute) problem, most ofﬁces try to
CareFirst BlueChoice to determine if authorization schedule you within 24-72 hours or less, depending
is available for treatment by an out-of-network on the urgency of the problem. The nurse or the
specialist. You don’t need a referral form for a appointment staff at your doctor’s ofﬁce will help
specialist visit. However, an authorization may be you determine how quickly you need to be seen.
required by the Plan for some services. Please refer
to your Evidence of Coverage to determine your
authorization requirements.

Medical Records
Each physician’s ofﬁce keeps a copy of your medical
records. If you are a new member, we encourage you to
transfer your previous medical records to your PCP’s
ofﬁce. Transferring your records to your PCP’s ofﬁce
will give your PCP easier access to your medical
history. Your previous physician may charge you a
fee for this transfer of records. Your medical records
are kept in conﬁdence and will only be released as
authorized by law. Please refer to the “Conﬁdentiality”
section on page 27 of this handbook for our guidelines
on the release of medical information.

www.carefirst.com 6
When You Need Care

Canceling appointments
If you are unable to keep a scheduled appointment, Examples of in-network care:
call the physician’s ofﬁce as soon as possible. Our
physicians prefer at least 24 hours notice so they ■ primary care physician visit;
can offer your appointment time to another patient.
Some physicians may charge a fee if you miss an ■ CareFirst BlueChoice specialist visit;
appointment and have not called to cancel.
■ diagnostic services, such as labs or
Laboratory Services x-rays, performed by CareFirst BlueChoice
Members must go to a LabCorp® facility for any independent laboratories or radiology
laboratory services in order to obtain coverage for centers; and
those services. LabCorp® is contracted to provide
■ hospitalization when authorization is
services for CareFirst BlueChoice members throughout
Maryland*, Virginia and Washington, DC. obtained by your PCP or another CareFirst
BlueChoice PCP or specialist.
Labwork performed in an outpatient hospital setting
will require a prior authorization.

Before going to the LabCorp® site, members must
have a LabCorp® requisition form or physician’s order
on a prescription pad or letterhead.

LabCorp® has approximately 70 locations in the
Maryland, Washington, DC and northern Virginia
area. If you need more information or need assistance
with lab requisitions, please call LabCorp® at (800)
322-3629. To locate the nearest LabCorp® patient
service center, call (888) LAB-CORP (522-2677), or
visit the LabCorp® web site at www.labcorp.com.

*Some exceptions apply in Western Maryland.

In-Network Beneﬁts
In-network care can be provided and coordinated
by your primary care physician (PCP). You may also
self refer to another CareFirst BlueChoice PCP or
specialist. Visits to a specialist are considered
in-network as long as you use a CareFirst BlueChoice
specialist. Generally, you only pay a nominal
copayment to a PCP, specialist or urgent care center
when you use in-network beneﬁts. The PCP
copayment will apply when services are received
from any CareFirst BlueChoice PCP. If you see a
specialist, you will pay the specialist copayment.
Covered diagnostic services are paid in full when
received at participating facilities.

7 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions
CareEssentials

Prevention heart health center for the information, quizzes and
tools to help manage these conditions.
Visit My Care First, the health and
wellness section of www.careﬁrst.com for You can also obtain personalized health information,
information that can help you manage your health. such as your body mass index, your target heart rate
and your ideal weight by using the health calculator.
At My Care First you will ﬁnd: For even more detail about your health, you can
register with the site. Registering will enable you
■ Information on over 300 health-related topics to take a personalized health assessment, set health
goals, track your progress and have reminders sent
■ Personalized health calculators that determine via e-mail. You can even get help to manage weight,
your body mass index or target heart rate stress or blood pressure and to quit smoking.

To visit My Care First, go to www.careﬁrst.com
Vitality Newsletter and click on “Health and Wellness – My Care First”
You may receive Vitality, our quarterly member in the Solution Center.
newsletter. Vitality can give you the tools you need to
help you achieve a happier and healthier lifestyle. Each Great Beginnings Program for
issue is ﬁlled with useful and timely information on Expectant Mothers
a variety of health-related topics. You’ll learn about CareFirst also offers Case Management support to
food and nutrition, physical ﬁtness, recreation and members during pregnancy. The Great Beginnings
preventive health care. You will also get to know program is designed to supplement the prenatal care
about our company and how to get the most from and education you receive from your doctor during
your beneﬁts. pregnancy. Our Case Managers strive to help you
and your baby stay healthy during pregnancy.
Get Healthy with My Care First
Looking for ways to get healthy and stay healthy? Go When you enroll in Great Beginnings, one of our
surﬁng–on the web, that is. Visit My Care First, the Case Managers will contact you to review your
health and wellness section of www.careﬁrst.com. medical history and to identify any other conditions
Our award-winning site contains a wealth of health that may affect your pregnancy. You will receive
information and interactive features that can help information related to your condition and your baby’s
you take an active role in managing your health. development. Your Case Manager will contact you
during each trimester to see how you are feeling and
If you are looking for information about a speciﬁc to answer any questions.
condition, just select a topic from our health library.
You can also learn about a variety of health issues If you have not chosen a pediatrician, the Case
from our weekly stories, quizzes and Health Scout Manager also may assist you in ﬁnding a pediatrician
news, which is updated several times a week. You also close to your home. If you experience any
can offer your opinion on a health issue by taking complications during pregnancy, your Case Manager
the weekly poll. will work closely with your doctor to coordinate
necessary services and provide additional support
If you or a loved one has asthma, diabetes or heart and information you may need during this time.
disease, visit our asthma center, diabetes center or

www.carefirst.com 8
CareEssentials

Case Managers are available to answer questions, If you would like a list of the speciﬁc
Monday through Friday, 8:30 am to 4:30 pm.
To ﬁnd out more information about the program,
call (888) 264-8648. guidelines, call Member Services at the

number listed on your member ID card.
Preventive Services Guidelines
You may also visit our web site at
Each year, CareFirst BlueChoice publishes a list of
preventive services guidelines. Preventive services
are procedures you should have, if applicable, to www.careﬁrst.com and click on
detect any health problems. Your physician
may recommend additional tests or exams. My Care First.
Adult preventive services include:

■ periodic physicals

■ blood pressure checks

■ height and weight monitoring

■ cholesterol testing

■ colon and prostate cancer testing

■ gynecological exams

■ testicular exams

■ diabetes screening

■ mammograms

■ immunizations

The preventive services for children include:

■ periodic physicals

■ blood pressure checks

■ height and weight monitoring

■ hearing and vision screenings

■ cholesterol and TB tests

■ growth, development and behavior assessments

■ immunizations

9 FirstHelp ® Health Care Advice Line: (800) 535-9700
CareEssentials

Utilization Management If you do not transfer to a CareFirst BlueChoice
hospital when medically able to do so, you will be
Utilization Management ensures that care
ﬁnancially responsible for the remaining charges of
is provided at the right time and in the
that hospitalization. A list of participating CareFirst
proper setting. Registered nurses and board-certiﬁed
BlueChoice hospitals can be located in the CareFirst
practitioners administer CareFirst BlueChoice’s
BlueChoice Provider Directory, or at our web site,
Utilization Management Program.
www.careﬁrst.com.
The program includes prior authorization Out-of-Network
requirements for certain services; review of
authorizations for hospital admissions according When the admitting physician does not participate in
to a nationally-accepted set of criteria; and the CareFirst BlueChoice network, you are responsible
retrospective review of treatment for which CareFirst for obtaining authorization from CareFirst BlueChoice.
BlueChoice did not give prior authorization. Failure to do so may result in a reduction or denial of
beneﬁts. Authorizations for hospitalizations will be
Hospital Care provided only if treatment cannot be provided on an
In-Network
outpatient basis. At the time of treatment, you may
need to provide payment in full to the hospital, doctor,
If you need to be hospitalized, your primary care or other covered providers. Use of your out-of-network
physician (PCP) or CareFirst BlueChoice specialist will beneﬁts generally results in a greater out-of-pocket
select a hospital and will make arrangements for your expense to you. You are responsible for a percentage of
admission. The hospital selected will usually be where CareFirst BlueChoice’s allowance for covered services
your PCP or specialist has admitting privileges. and for any balances up to the provider’s charge.
Discuss all the details of your admission in advance Obtaining Authorization
with your PCP or CareFirst BlueChoice specialist.
Authorization must be obtained at least ﬁve business
You may want to ask about details such as length
days before the anticipated date upon which
of stay, special diets or procedures. Knowing the
treatment will start or the admission date for an
answers in advance can make your stay easier and
elective or planned hospitalization. If the admission
more comfortable.
cannot be scheduled in advance because it is not
Some outpatient hospital procedures, such as medically feasible to delay the admission for ﬁve
outpatient diagnostic services, pre-admission testing business days due to the member’s medical condition,
or surgery, may be subject to approval by CareFirst we must receive notiﬁcation of the admission as soon
BlueChoice. Again, your CareFirst BlueChoice as possible. Authorization for an emergency admission
admitting physician will coordinate with CareFirst must be obtained within 48 hours of the admission or
BlueChoice regarding authorization requirements. by the end of the ﬁrst business day following the
When you ﬁll out the admission or registration papers beginning of the admission, whichever is earlier.
at the hospital, be sure to indicate that you have
In-Network: Requirements are handled by your
coverage through CareFirst BlueChoice.
CareFirst BlueChoice providers. Your PCP or the
In-network beneﬁts will not be provided for services CareFirst BlueChoice specialist who admits you to the
rendered in a non-CareFirst BlueChoice hospital, hospital in conjunction with the hospital is responsible
except in certain emergency situations. If you are for obtaining the authorization.
admitted to a non-CareFirst BlueChoice hospital,
Out-of-Network: When using out-of-network beneﬁts,
you may be transferred to a CareFirst BlueChoice-
you or your representative must call Utilization
approved hospital as soon as medically feasible.
Management at (866) PREAUTH (773-2884) (this
telephone number is also on the back of your member
ID card). Failure to do so may result in a reduction or
denial of beneﬁts. Utilization Management ofﬁce hours
are 8:30 am to 7:00 pm (EST), Monday through Friday.

www.carefirst.com 10
CareEssentials

Continued Stay Review Case Managers are registered nurses who play an active
After your hospital admission has been authorized, a role in working with your primary care physician to
Care Management nurse, working in conjunction with help develop a plan of care that will ensure that you
a CareFirst BlueChoice Medical Director, will review receive the best possible care in an efﬁcient and timely
your admission to determine if additional inpatient manner. Your relationship with your Case Manager
hospital days are medically necessary. This type of enables you to receive prompt answers to any of your
review is known as Continued Stay Review. Your questions or concerns.
physician, a hospital representative and the Care
Management nurse will coordinate the approval of Please keep in mind that since this program is
additional hospital days. The Care Management nurse voluntary you can withdraw at any time without
can also assist with discharge planning as needed. a penalty.
If it is determined that extra days are not medically
necessary, your doctor will be notiﬁed.
When appropriate, Case Management can
Disease Management Programs help you with conditions such as (but not
Disease Management Programs provide limited to):
eligible members with educational
materials and reminders that enable them to manage ■ Spinal Cord Injury
chronic diseases. In more serious cases, Case Managers
■ Amputation
make telephone contact with members and their
doctors. CareFirst BlueChoice has programs for ■ AIDS
asthma, COPD, diabetes and heart disease.
■ Asthma
Members who enroll receive educational materials that
will help them better understand and manage their ■ Burns
condition. Members are also given telephone access
■ Cancer
to a nurse who can answer their questions about
medications, tests their doctor ordered or other ■ Diabetes
concerns related to their condition. All of these
programs are voluntary and are provided at no ■ Heart Disease
additional cost to eligible members.
■ High Risk Newborns
Case Management Program
■ High Risk Pregnancies
When faced with health care decisions, you
and your family may have many questions ■ Multiple Fractures
and difﬁcult choices to make. The Case Management
Department of CareFirst BlueChoice wants to make ■ Severe Head Trauma
sure you get all the help you need for any health
■ Stroke
problems or concerns you may have.

The Case Management Program is part of your
medical beneﬁts. As a member of CareFirst If you want to enroll or would like more information
BlueChoice, you will not be charged any fee for this about the Case Management Program, please
service. It’s one of the ways we can help you to remain call (888) 264-8648, Monday through Friday
active and in the best health possible. between 8:30 am and 4:30 pm.

11 FirstHelp ® Health Care Advice Line: (800) 535-9700
Options Discount Program
Frequently Asked Questions
Options is a discount program provided to members of members only. If you are already a club member (or
CareFirst BlueChoice. Because this is a discount program were a member in the last 90 days**) you are not
and not a covered beneﬁt, there are no claim forms, eligible for the discounted rate. The only exception
referrals or paperwork. To receive these discounts, simply is Bally Total Fitness. After you have completed
show your BlueChoice ID card or visit the special website your current Bally contract, you are eligible for the
for members if it’s an online program. In order to be discounted rate.
responsive to your needs, Options continually adds new
services. Visit www.careﬁrst.com/options for the latest ** There are a limited number of clubs that require a
Options programs. longer “run-out” period than 90 days. Please contact
GlobalFit for more information.
Discounts Include:
Healthways WholeHealth Networks offers a
Weight Loss Assistance Programs nationwide network of approximately 2,900 ﬁtness
centers and spas. With your CareFirst BlueChoice
Weight Watchers, one of the nation’s most recognized plan, you can receive discounts on the following:
weight loss programs is online, and CareFirst
BlueChoice members can save $10 on a 3-month ■ 10-50% off ﬁtness center initiation fees and/or
subscription to Weight Watchers Online®. Weight membership dues
Watchers Online® provides a set of personalized ■ Spa memberships or services ranging from 10-30%
weight loss tools, such as Online Journal, Meal
Planner, Weight Tracker, and Progress Charts. Search NOTE: Membership obligations for ﬁtness centers
a database of more than 800 Weight Watchers recipes and discounted spa services are based on individual
and calculate POINTS® for your own foods and meals. location policies.
Join Jenny Craig and receive a FREE 30-day program*. National Fitness Network consists of approximately
Jenny Craig will design a personalized comprehensive 100 independent regional health clubs*** and is the
program with one-on-one support, that ﬁts your lifestyle. only health club network that offers the convenience
You can also enjoy up to 50% off the 6-month program* of unlimited access to its entire network of clubs with
or 20% off the 1-year Premium Success Program*. a single membership. There is no need to select a
primary club or transfer your membership. National
* Plus the cost of food and shipping when applicable. Fitness Network offers the following discounts:
Discounts apply to membership fee only. Offer good at
participating Centres and Jenny Direct® in the United
States, Canada and Puerto Rico.
and $29 for each additional family member.
Fitness Club Memberships
Through 3 different networks, Options offers NOTE: To receive a discount, you must enroll directly
ﬂexibility in choosing a gym that is right for you. through the National Fitness Network. If you are
With GlobalFit’s lowest price guarantee, you’ll receive already a member of a National Fitness Network club,
the best available rates at more than 10,000 ﬁtness you must complete your current contract before you
clubs nationwide, including Bally Total Fitness clubs can get the discounted rate.
and Curves, all with month-to-month memberships
and no long-term contracts. ***Available in MD, DC, VA, NJ, and FL only.
NOTE: Discounts in GlobalFit clubs are for new

www.carefirst.com 12
Options Discount Program

Hearing Care Services ElderCare Information & Referral Program
Better hearing enriches your quality of life. Take ElderCarelink is a free, internet-based service that
advantage of the many discounted services offered by specializes in providing referrals for services for elders
both Beltone Hearing Care Centers and TruHearing. and their families. Services include home health care,
With Beltone, parents, children, spouses and home support, assisted living, adult day care, long-
grandparents receive free hearing screenings and a 25% term care, nursing home options and more. Members
discount off the cost of Beltone hearing aids. All Beltone ﬁll out a needs assessment online survey and then
hearing aids include free batteries for one year, a two- ElderCarelink will e-mail a list of participating
year warranty, free cleaning and minor repairs and network providers that match your needs. Members
adjustments for the life of the hearing aid. TruHearing are also eligible to receive a free 90-day subscription
offers free hearing screenings and discounts of up to 60% to The Caregiver’s Home Companion newsletter.
off quality digital instruments for CareFirst BlueChoice
members, their children, parents, and grandparents. Alternative Health & Wellness Services
TruHearing also offers an extended two-year warranty
and a 45-day money back guarantee. All hearing tests are The following services are offered through Healthways
performed using the latest diagnostic equipment. WholeHealth Networks, Inc. Through the Options
program, members can receive up to a 30% discount
on these alternative health and wellness services.
Laser Vision Correction & Contact Lenses
■ Acupuncture ■ Mind-Body
Through TruVision, CareFirst BlueChoice members
■ Chiropractic Care Instruction
can receive 10% off of LASIK or PRK procedures.
■ Guided Imagery ■ Nutrition Counseling
All pricing includes a pre-operative exam, the Laser
■ Magazine Discount ■ Personal Training/
Vision Correction procedure, post-operative care
Program Pilates
and a one-year enhancement warranty. Discounts
■ Massage Therapy ■ Qi Gong/Tai Chi
are also available on Custom LASIK, IntraLase
■ Meditation Instruction ■ Yoga
Bladeless procedures, and some centers offer lifetime
re-treatment plans. Members can also receive
discounts of up to 50% off most brands of contact
lenses ordered through the Mail and receive free
shipping and handling.

QualSight provides affordable access to quality laser
vision correction services at 600 locations nationwide. In addition to the Options program, the Blue
QualSight partners with leading ophthalmologists Cross and Blue Shield Association gives you ac-
and credentials each doctor in order to verify their cess to even more discounts through Blue365.
experience and work history. Included in the $895 price Blue365 provides tools and guides to help you
per eye are the pre-operative exam, LASIK or PRK learn more about wellness services that go be-
procedure, post-operative exams, and a retreatment yond your covered services. There are four key
warranty. Discounts are also available on Custom areas of Blue365:
LASIK, Conductive Keratoplasty, and IntraLase.
■ Health and Wellness
Medical IDs ■ Family Care
■ Health-Focused Financial Services
American Medical ID offers a 22% discount on ■ Travel Information
customized medical identiﬁcation bracelets and
necklaces. Medical IDs allow medics or other medical Want to know more about what Blue365 has
professionals to give prompt, precise treatment in a to offer? Look for the list of Blue365 vendors
medical emergency. They help ensure a patient will and resources on a special Web site designed
receive proper care, eliminate unnecessary testing just for BlueChoice members. It’s all available
and reduce the chance of costly medical errors. Those at www.carefirst.com/options. You can also
who have chronic medical conditions, drug or food call Member Services for more information
allergies, or are taking multiple medicines, are advised on Blue365.
to wear a medical ID.

13 FirstHelp ® Health Care Advice Line: (800) 535-9700
Options Discount Program

Visit www.careﬁrst.com/options for more information on these services or see the following
contact information below.

Options Program Directory
Alternative Health Healthways WholeHealth Networks, Inc. (800) 514-6502
& Wellness Services http://options.wholehealthmd.com

Eldercare Information ElderCarelink (866) 451-5577
& Referrals www.eldercarelink.com/careﬁrst
GlobalFit (800) 294-1500
www.globalﬁt.com

Healthways WholeHealth Netowrk (800) 514-6502
Fitness Centers http://options.wholehealthmd.com

National Fitness Network (800) 811-5454
www.nationalﬁtnessnetwork.com
Beltone (800) 235-8663
www.beltone.com
Hearing Care
TruHearing (877) 587-3937
www.truhearing.com
QualSight LASIK (877) 285-2010
www.qualsight.com/-careﬁrst
Laser Vision Correction
TruVision LASIK* (800) 398-7075
& Contact Lenses
www.truvision.com/careﬁrst/LASIK.htm
*Also offers discounts on mail-order contact lenses

American Medical ID (800) 363-5985
Medical IDs www.americanmedical-id.com/extras/careﬁrst.php
Weight Watchers Online®
Weight Loss www.weightwatchers.com/cs/cfbcbs
& Management Jenny Craig® (800) 96-JENNY
www.jennycraig.com/corporatechannel/careﬁrst.aspx

www.carefirst.com 14
Frequently and Urgent Care
Emergency Asked Questions
When you have a medical emergency, your health care
coverage is not the ﬁrst thought that comes to mind.
We encourage you to become familiar with this section Urgent Care
so you’ll know how to get the maximum beneﬁts An “Urgent Condition” is a condition that
available under the policy if you should have a is not a threat to life or limb, but does
medical emergency. require prompt medical attention.

If the situation is urgent:

■ Contact your PCP. If your PCP is
Medical Emergencies
unavailable or if you are unsure about
If the situation is a medical emergency: the meaning or seriousness of the
symptoms, you can call FirstHelp® at
■ call 911 or (800) 535-9700 for medical advice
■ go directly to the nearest
or
emergency facility.
■ Go directly to an urgent care center. A
list of participating CareFirst BlueChoice
A “Medical Emergency” is the sudden onset
Urgent Care Centers can be found in the
of a serious illness or injury that in the
CareFirst BlueChoice Provider Directory
absence of immediate medical attention
or on our web site at www.careﬁrst.com.
could reasonably be expected by a prudent
layperson (one who possesses an average
knowledge of health and medicine)
to result in:
Urgent Care Centers
■ serious jeopardy to the patient’s health; Urgent care centers are walk-in medical facilities
equipped to handle minor emergencies. Most centers
■ serious impairment to bodily functions; have evening and weekend hours should a condition
require immediate attention and you are unable to
■ serious dysfunction of any bodily organ reach your PCP. Urgent care centers are typically
or part; or conveniently located and often allow you to be seen
more quickly than in an emergency room.
■ in the case of a pregnant woman, serious
jeopardy to the health of the fetus. You may refer to the list of urgent care centers in
your CareFirst BlueChoice Provider Directory or
call FirstHelp® for a participating urgent care
center near you.
An authorization is not needed for emergency
room services. Remember, urgent care centers do not take the place
of your PCP. Your PCP should be your ﬁrst contact
whenever you need medical care.

15 FirstHelp ® Health Care Advice Line: (800) 535-9700
Emergency and Urgent Care

FirstHelp®: 24-Hour Emergency
Assistance and Medical Advice Care When Traveling
If you believe a situation is a medical emergency, call ■ Seek medical attention immediately in the
911 immediately or go to the nearest emergency case of emergencies and urgent conditions.
facility. In an urgent situation, contact your PCP for
advice. If your PCP is not available and you have ■ If you are unsure about the meaning or
symptoms and don’t know exactly what they mean or seriousness of the symptoms, call FirstHelp®
how serious they are, CareFirst BlueChoice provides at (800) 535-9700 for medical advice.
you with FirstHelp®, a 24-Hour Emergency Assistance
and Medical Advice hotline. Here’s how it works:

1. If you are unable to reach your PCP, call FirstHelp®, BlueCard® Program
our 24-Hour Medical Advice/Emergency Assistance As a CareFirst BlueChoice Opt-Out member, your
Service at (800) 535-9700. (The telephone number beneﬁts include the BlueCard® program for out-of-
is also listed on the back of your identiﬁcation card.) area emergency and urgent care situations. The
Your call will be answered promptly by an BlueCard® program is a beneﬁt because when you
experienced registered nurse. see an out-of-area participating Blue Cross and Blue
Shield physician or hospital for emergency or urgent
2. If the nurse determines that your situation is a care, you will only be responsible for paying out-of-
medical emergency, he or she will advise you to pocket expenses (copayment), and your beneﬁts will
seek immediate medical care. NOTE: If taking the be paid at the in-network level. This relieves you of the
time to call FirstHelp® would seriously jeopardize hassle and worry of paying for the entire visit up-front
your health, call 911 directly or go to an emergency and then ﬁling a claim form later. The participating
facility immediately. BlueCross BlueShield physician or hospital will ﬁle the
claim directly to the local BlueCross BlueShield plan.
3. If your condition is not an emergency situation, the In turn, the participating provider will be reimbursed
nurse will ask you about your symptoms. The nurse directly on your behalf.
will then make recommendations to help you decide
the safest and most appropriate course of action, To use the BlueCard® program for out-of-area
whether it’s a participating urgent care center, an emergency and urgent care, please call (800) 810-BLUE
appointment at your PCP’s ofﬁce, or self-care. (2583) to locate the nearest Blue Cross and Blue Shield
physicians and hospitals. At the time of service,
4. If the nurse recommends self-care, he or she will present your member ID card.
educate you about your condition, explain what to
do for pain or symptom relief and tell you what to If you do not use the BlueCard® program for out-of-
expect or watch for. The nurse may also call you the area emergency or urgent care, the physician or hospi-
next day to check on your condition. tal should bill CareFirst BlueChoice directly. However,
if an up-front payment is requested, obtain itemized
If your urgent condition is related to mental health or receipts and contact Member Services when you return
substance abuse, see the section “Seeing Mental Health to obtain a claim form for consideration and
Specialists” on page 18 of this handbook. reimbursement of charges.

For more information, see the section on “Filing a Claim
® for Reimbursement” on page 22 of this handbook.
FirstHelp 24-Hour
Emergency Assistance and
Medical Advice Hotline
(800) 535-9700

www.carefirst.com 16
Emergency and Urgent Care

Follow-Up Care The Coordinator will:
If your condition requires follow-up care after your 1. Check your CareFirst BlueChoice eligibility.
initial visit to an urgent care center or hospital
emergency room, you should contact your PCP. 2. Obtain the appropriate information
In-network beneﬁts may not be available for (e.g., destination, duration of stay).
follow-up care performed in an urgent care center
or hospital emergency room for additional services 3. Determine if there is a participating afﬁliated HMO
related to the initial condition. available in the area where you or your dependents
are visiting. If there are no participating afﬁliated
In-network beneﬁts are applied to medical emergency HMOs in the area, the program will not be
care. In most cases, out-of-network beneﬁts will be available to you.
applied to follow-up care received at an urgent care
center or hospital. 4. Explain how the program works if there is an
afﬁliated HMO available in the destination area.
The physician at the emergency room or urgent care
center cannot refer you to a specialist for follow-up 5. Send the application to you for your signature, and
care. You should contact your PCP for a referral to a once the signed application is returned, submit it
specialist. You can always contact Member Services to to the afﬁliated HMO.
determine if you are following the correct procedures
to receive the highest level of beneﬁts.

The Away From Home Care® Program
The Away From Home Care® program allows CareFirst
BlueChoice members and their dependents to receive
care when they are away from home for at least 90
days. The care can be provided by an afﬁliated Blue
Cross and Blue Shield HMO outside of the CareFirst
BlueChoice service area (Maryland, Washington, DC,
and northern Virginia). Whether it is extended
out-of-town business or travel, semesters at school or
families living apart, with the Away From Home Care®
program, members can enjoy a full range of beneﬁts.
This includes, but is not limited to routine and
preventive care. Your copay and beneﬁts will be those
of the afﬁliated HMO in the area where you are
visiting. You will be treated as though you are actually
a member of the afﬁliated plan.

Where can I obtain more information and enroll
in the Away From Home Care® program?
If you would like to obtain more information or enroll
in the Away From Home Care® program, please call
the CareFirst BlueChoice Member Services number
on the front of your CareFirst BlueChoice ID card and
ask to be transferred to the Away From Home Care®
Coordinator.

17 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions
Seeing Mental Health Specialists
Your health care coverage includes mental health and This is especially important if you are receiving
substance abuse beneﬁts. Mental health and substance medications, since your PCP will then be able to
abuse beneﬁts may be subject to day and/or visit monitor potential interactions related to any other
limitations. Also, certain conditions may be excluded, medications that may be prescribed for you. By
such as chronic, long-term or ongoing conditions. working with your PCP and other practitioners, you
can assist in the continuity and effective coordination
Please consult your Evidence of Coverage for speciﬁc of your health care.
information about your particular coverage, or call
Member Services for more information. To be eligible for in-network beneﬁts, both mental
health and substance abuse services must be
How to obtain in-network mental health care coordinated through our administrator. Please
If you think you are in need of mental health or refer to your Evidence of Coverage to identify your
substance abuse care, you must ﬁrst call the Mental speciﬁc mental health and substance abuse beneﬁts.
Health/Substance Abuse Service and Authorization
phone number on the back of your identiﬁcation card. For mental health and substance abuse care, including
A trained representative will ask you basic questions emergencies, call the Mental Health/Substance Abuse
and explain your beneﬁts. A Case Manager will Service and Authorization telephone number on the
discuss your situation with you and evaluate the most back of your identiﬁcation card. Service is available
appropriate plan of treatment. If the patient is a child 24 hours a day, 7 days a week.
or an adolescent, the parent or guardian may provide
the necessary information. How to Obtain Out-of-Network Mental
Health Care
Based on your discussion with the Case Manager, You may self-refer for covered outpatient services
you may be referred to a mental health provider to or partial hospitalization to any covered provider.
treat your condition. Once you have been referred, However, for inpatient hospital admissions, you must
your network provider will work directly with the ﬁrst contact our mental health and substance abuse
Case Manager to obtain authorization for any administrator for authorization.
additional treatment.

Mental health and substance abuse services must
be coordinated through our mental health and Exclusions
substance abuse administrator rather than through ■ Depending on your contract, beneﬁts might
your PCP. However, if you wish, you may ﬁrst not be available for the services rendered
discuss your concerns with your doctor. Your PCP by all providers listed in the CareFirst
may contact our mental health and substance abuse BlueChoice Provider Directories.
administrator on your behalf. If you receive
ongoing care from a mental health practitioner, we ■ Please refer to your Evidence of Coverage for
suggest that you have this practitioner send regular speciﬁc information regarding exclusions
reports regarding your treatment directly to your PCP. from your coverage.

www.carefirst.com 18
Additional Beneﬁts
Frequently Asked Questions
Dental Beneﬁts Preferred (PPO) Dental
Your beneﬁts may include dental coverage. Details CareFirst’s Preferred (PPO) Dental offers both
about your dental coverage are located in your savings and choice. CareFirst has developed a
Evidence of Coverage. network of 3,400 preferred dentists who have agreed
to provide care at a discount. Once you meet your
annual deductible, you can save money by paying a
If you have dental beneﬁts, you have access to lower coinsurance amount when using a dentist in the
the following services: Preferred network, and have no claim forms to ﬁle.
If you receive care outside the Preferred network, you
■ Preventive care may have to ﬁle your own claim forms and pay more
out-of-pocket for your care.
■ X-rays
Dental HMO
■ Fillings and restorative services
The Dental Network, Inc. (TDN) is the administrator for
■ Oral surgery and periodontal care CareFirst’s Dental HMO (DHMO) plans. As a DHMO
member, you choose a Primary Care Dentist (PCD)
■ Emergency care from a carefully selected network. All dental services
are provided for the cost of a copay – there are no
Your dental coverage may also include orthodontia. deductibles to meet, no claim forms to ﬁle and no
annual maximums. If you have not selected a PCD
or have questions about your DHMO dental
For information on dental coverage, please call the coverage, please contact TDN at (410) 847-9060
Member Services phone number on front of your or (888) 833-8464.
member ID card or the Dental Member Services
number located on the back of your identiﬁcation card. CareFirst BlueCross BlueShield is the business name
of Group Hospitalization and Medical Services, Inc.
The following is a list of dental plans for which you CareFirst BlueChoice and TDN are independent licensees
may be eligible if you purchase coverage through your of the Blue Cross and Blue Shield Association.
employer. Members with individual coverage are only
eligible for Dental HMO coverage. Prescription Beneﬁts
Your coverage may include beneﬁts for outpatient
Traditional Dental
prescription drugs. Please review your Evidence
CareFirst BlueCross BlueShield’s (CareFirst) traditional of Coverage to determine whether or not you have
Dental allows you the freedom to seek dental care beneﬁts for outpatient prescription medications
from any dentist and the opportunity to reduce under your BlueChoice Opt-Out plan.
out-of-pocket costs. When you visit a participating
dentist, you have no claims to ﬁle and are only
responsible for applicable deductibles and coinsurance.
If you seek care from a non-participating dentist, you
will be required to ﬁle claims yourself and you may
incur higher out-of-pocket costs. More than 3,800
dentists participate with CareFirst – you may already
be seeing a CareFirst participating dentist.

19 FirstHelp ® Health Care Advice Line: (800) 535-9700
Additional Beneﬁts

CareFirst BlueChoice uses a preferred drug list (also Here are simple steps you can take:
called a formulary), which is a list of generic (tier 1)
and certain preferred brand-name (tier 2) drugs. Drugs 1. Know your out-of-pocket costs. Use the
that are not on the formulary are called non-preferred online database or price comparison tool at
(tier 3) drugs and are covered as part of your plan, www.careﬁrst.com to learn more about the
although your payment will be more for these drugs. If costs of your medications.
you are prescribed a non-preferred brand-name drug,
discuss alternatives that are on the preferred drug list 2. Talk with your doctor. Print a copy of our current
with your doctor. preferred drug list to bring to your next doctor’s
visit. Discuss the medicines you are taking and if
How often does the preferred drug list change? they are on the preferred drug list. If your medicine
As often as needed, but usually no more than a few is not on this list –a tier 3 or non-preferred brand
times each year. Drugs on the preferred drug list are name drug– ask if there are more affordable
selected by a committee of practicing physicians and alternatives that may be right for you.
pharmacists from the community and CareFirst
3. Use a participating pharmacy. There are more than
BlueChoice and are chosen because of their quality, 59,000 participating pharmacies nationwide that
effectiveness, safety and cost. The preferred drug list accept your prescription drug card. Choose one
also changes as new drugs enter the market and that’s convenient, but remember to shop around.
as generic equivalents become available. Some pharmacies charge more than others, and if
For the most current preferred drug list, please you have a plan with coinsurance, those prices may
visit www.careﬁrst.com. affect how much you pay.
Prior Authorization 4. Don’t forget your member ID card. To help ensure
Even if a drug is on our preferred drug list, it may you receive proper service, the pharmacist will
still require advance approval, or prior authorization, need your member ID card and a prescription
before it can be ﬁlled. The patient’s physician should from your doctor.
begin the authorization process before they visit the
pharmacy. If prior authorization is not obtained or is 5. Be on the lookout for alternatives. New medicines
denied, the drug will not be covered. If you are already become available often, so the price of your
at the pharmacy and ﬁnd that the drug needs prior prescription may rise or fall as a result. Changes
authorization, you should have the pharmacist call the in the preferred drug list often happen because a
prescribing doctor and request that he/she begin the new medicine is introduced to the marketplace
authorization process. or a generic becomes available.

Questions Some of these tips apply only to members whose
Argus Health Systems (Argus), our pharmacy claims prescription drug beneﬁt is based on the CareFirst
processor, administers the CareFirst BlueChoice BlueChoice preferred drug list.
prescription drug program. If you have any questions
about your prescription drug coverage, call Argus Vision Beneﬁts
Member Services at (800) 241-3371 or visit the Your coverage may include beneﬁts for vision
Prescription Drug section in the Members & Visitors care under BlueVision or BlueVision Plus. Please
area of www.careﬁrst.com. review your Evidence of Coverage to determine
if your coverage includes beneﬁts for vision care.
How to Manage Medication Costs BluePreferred members with individual coverage
Our prescription drug beneﬁt already saves you money are only eligible for BlueVision coverage.
on prescription costs. However, you also may have
other alternatives to lower your costs while getting CareFirst BlueChoice is pleased to offer BlueVision
medicines that treat your condition. and BlueVision Plus to meet your vision needs. These
vision plans are administered by Davis Vision, Inc., a
national provider of vision care services.

www.carefirst.com 20
Additional Beneﬁts

BlueVision How to Access Out-of-Network
BlueVision provides a routine vision examination
Vision Care
(including dilation) once per beneﬁt period for a Out-of-Network care varies according to plan. Some
$10 copay when you visit a participating Davis Vision plans allow out-of-network care while others do not.
provider. Through Davis Vision, you also receive Refer to your Evidence of Coverage to ﬁnd out what
discounts on eyeglass lenses and frames or contact beneﬁts you have under your plan.
lenses, as well as laser vision correction surgery. Refer
to your Evidence of Coverage to ﬁnd out what If you choose an out-of-network provider, you will
beneﬁts you have under your plan. be required to pay the provider directly for all charges
and then submit a claim for reimbursement to:
BlueVision Plus
Vision Care Processing Unit
BlueVision Plus provides an extended beneﬁt that P.O. Box 1525
includes an eye examination (including dilation) and Latham, NY 12110
coverage for eyeglasses or contact lenses once per
beneﬁt period. Eyeglass frames and lenses are covered Only one claim per service may be submitted for
in full when you choose from Davis Vision’s Exclusive reimbursement each beneﬁt cycle. To print claim
Tower Collection of approximately 270 frames, or forms, visit the “Members & Visitors” section of
you can receive an allowance toward any other frame. www.careﬁrst.com and click on “Forms” or call
You can also receive coverage for contact lenses in lieu (800) 783-5602 to request claim forms.
of eyeglasses when you choose Davis Vision contact
lenses. The choice is yours! Additionally, Davis Vision
offers discounts on laser vision correction surgery,
additional lens treatments and coatings. Refer to your
Evidence of Coverage to ﬁnd out what beneﬁts you
have under your plan.

With BlueVision Plus you may receive services from
out-of-network providers in addition to in-network
providers, although you will receive the greatest value
and maximize your beneﬁt dollars if you select a
provider who participates in the network.

How to Access In-Network Vision Care
■ Call (800) 783-5602 for a list of providers
nearest you, or access the network through
www.careﬁrst.com. Just click on Find a
Doctor in the Solution Center.

■ Call the Davis Vision provider of your choice
and schedule an appointment.

■ Identify yourself as a CareFirst BlueChoice
member and a Davis Vision plan participant.

■ Provide the ofﬁce with the member’s
identiﬁcation number and the year of birth
of any covered dependents needing services.

■ The provider’s ofﬁce will verify your eligibility
for services and no claim forms are required.

21 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Your Plan
Administration ofQuestions
Personal and Enrollment Changes Provider Reimbursement
If you change your name, address or phone number, CareFirst BlueChoice providers are paid on a fee-for-
please contact Member Services and we will update our service basis. This means that CareFirst BlueChoice
records or advise you of any forms you need to submit. providers receive beneﬁt payments according to a
Remember, we need your correct address to keep you fee schedule for covered services they perform. You
informed about critical program information may contact Member Services to obtain additional
including policies, procedures and beneﬁt changes. information about provider payment arrangements.

If you have group coverage and you wish to enroll Other Insurance
or disenroll a dependent (including newborns) or When you or your dependents have additional
change your marital status, you must notify your coverage under another health plan or insurance
employer within the time frame speciﬁed in your program (for example, a plan through your spouse’s
Evidence of Coverage. Individual contract members employer or Medicare) coordination of beneﬁts
must notify CareFirst BlueChoice in writing to make (COB) may apply. COB eliminates duplicate payments
enrollment changes. for the same expense and plays an important role
in controlling the price you pay for your health
Filing a Claim for Reimbursement care coverage.
An advantage of your BlueChoice Opt-Out coverage
is that you do not have to ﬁle claims. CareFirst While it is important that you receive the health
BlueChoice and CareFirst BlueCross BlueShield beneﬁts for which you are eligible, it is just as
providers are required to submit claims. All you have important that payments are properly coordinated so
to do is pay any necessary copayment at the time that one health insurance carrier does not exceed its
of the visit. If you do need to submit a claim for payment responsibility for your bill. The combined
services rendered by a provider who does not payment by CareFirst BlueChoice and the other plan
participate in the CareFirst BlueChoice or CareFirst should not be more than the total amount of the bill.
BlueCross BlueShield network (such as emergency
care received outside the service area), you may contact We update our COB information periodically;
Member Services for a CareFirst BlueChoice Health however, should your other insurance change, please
Beneﬁts Claim Form or print one from our web site let us know so we can update our records. Even if you
at www.careﬁrst.com. Be sure to attach a complete do not have other insurance, it is important that you
itemized bill prepared by the provider of service provide that information to us so that we may keep
that includes the charges for each service along with your records current, which will ensure the quick or
the medical condition for which the treatment was expedited processing of your claims. To supply this
performed. Submit the completed claim form and information, you may call our COB department
attachments to: at (866) 285-2611, or you may download a COB
form in the Forms section of our web site at
CareFirst BlueChoice, Inc. www.careﬁrst.com. Rules to determine how
P.O. Box 804 beneﬁts are coordinated are outlined in your
Owings Mills, MD 21117-9998 Evidence of Coverage.

All claims must be ﬁled within the time limit speciﬁed in
your Evidence of Coverage.

www.carefirst.com 22
Administration of Your Plan

Virginia:
Member Satisfaction Ofﬁce of the Managed Care Ombudsman
Bureau of Insurance
CareFirst BlueChoice wants to hear your P.O. Box 1157
concerns and/or complaints so they may be Richmond,VA 23218
resolved. We have procedures that address (877) 310-6560 or (804) 371-9032
medical and non-medical issues. If a situation ombudsman@scc.virginia.gov
should occur for which there is any question
Center for Quality Health Care Services
or difﬁculty, here’s what to do: and Consumer Protection
Virginia Department of Health
■ If your comment or concern is regarding the 3600 W. Broad Street, Suite 216
quality of service received from a CareFirst Richmond,VA 23230
BlueChoice representative or administrative (800) 955-1819 or (804) 367-2104
problems (e.g., enrollment, claims, bills, etc.), Fax: (804) 367-2149
you should contact Member Services. If you mchip@vdh.virginia.gov
send your comments to us in writing, please
include your identiﬁcation number and
District of Columbia:
provide us with as much detail as possible. Medical Necessity Issues:
Please include your daytime telephone Department of Health
number so that we may contact you directly Ofﬁce of the General Counsel
Grievance and Appeals Coordinator
if we need additional information. 825 North Capitol Street, NE
Washington, DC 20002
■ If your concern or complaint is about the (202) 442-5977
quality of care or quality of service received Fax: (202) 442-4797
from a speciﬁc provider, contact Member
Services. A representative will record your Issues other than Medical Necessity:
Department of Insurance, Securities, and Banking
concerns and may request a written summary 810 First Street, NE, Suite 701
of the issues. If you send your comments Washington, DC 20002
to us in writing, please include your (202) 727-8000
identiﬁcation number and provide us with
as much detail as possible regarding any Maryland:
events. Please include your daytime telephone Maryland Insurance Administration
number so that we may contact you directly if Inquiry and Investigation, Life and Health
we need additional information. Our Quality 200 St. Paul Place, Suite 2700
Improvement department will investigate your Baltimore, MD 21202-2272
concerns, share those issues with the provider (410) 468-2000 or (800) 492-6116
involved and request a response. We will then Fax: (410) 468-2270
www.mdinsurance.state.md.us
provide you with a summary of our ﬁndings.
CareFirst BlueChoice member complaints are Health Education and Advocacy Unit
retained in our provider ﬁles and are reviewed Consumer Protection Division
when providers are considered for continuing Ofﬁce of the Attorney General
200 St. Paul Place
participation with CareFirst BlueChoice.
Baltimore, MD 21202
(410) 528-1840 or (887) 261-8807
These procedures are also outlined in your Fax: (410) 576-6571
Evidence of Coverage. www.oag.state.md.us
Ofﬁce of Health Care Quality
Spring Grove Center
Bland-Bryant Building
55 Wade Avenue
If you wish, you may also contact the appropriate Catonsville, MD 21228
jurisdiction’s regulatory department regarding (877) 402-8218
your concern: Fax: (410) 402-8215
www.dhmh.state.md.us/ohcq

23 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions
Appeals Process
Frequently Asked Questions
CareFirst BlueChoice’s appeal procedure is designed Services Department. A Member Services
to enable you to have your concerns regarding a denial representative will be available to assist you in
of beneﬁts or authorization for services heard and submitting your appeal in the event you are unable
resolved. By following the steps outlined below, you to put the request in writing. All appeal decisions
can ensure that your appeal is quickly and responsively will be rendered in writing to the member.
addressed. Please note that state mandates may alter
the steps below. Refer to your Evidence of Coverage If the decision remains as a denial of the original
for more speciﬁc information regarding your request, a detailed explanation that references the rule,
appeal process. policy or guideline used to make the decision will be
included. Also provided will be an explanation of the
An expedited appeal process has been established in appropriate next steps a member may take if he or she
the event that a delay in a decision would be is not satisﬁed with the appeal process.
detrimental to your health or the health of a covered
family member. In an expedited appeal, a decision by Members have a right to an independent external
CareFirst BlueChoice shall be made within 24 hours review of any ﬁnal appeal or grievance determination.
from the time we receive the appeal. Review will be If you wish, you may contact the insurance
done by a physician in the same or similar specialty regulatory department in your area to ﬁle a complaint
as the treatment under review and not part of the or an appeal regarding a denial or reduction of
original denial decision, as appropriate. Expedited beneﬁts. The procedure for ﬁling an appeal is also
appeals involve care that has not yet occurred or is cur- located on our web site at www.careﬁrst.com. In the
rently occurring (pre-service or concurrent care). Members & Visitors section, click on “Frequently Asked
Questions” in the Solution Center. If you would like a
Step 1: Discussion of the problem paper copy of the appeal process, you may also contact
Your concerns can often be handled and resolved the Member Services telephone number
through informal discussions and information located on your member ID card.
gathering. If your question relates to our handling
of a claim or other administrative action, call and
discuss the matter with a CareFirst BlueChoice
Member Services representative. In many instances,
the matter can be quickly resolved.

Step 2: Appeal/grievance process
If your concern is not resolved through a discussion
with a CareFirst BlueChoice representative, you or
someone on your behalf may make a formal request
for appeal. CareFirst BlueChoice must receive the
request within 180 days of the date of receipt of
notiﬁcation of denial of beneﬁts or services. If the
request for appeal is related to a medical or clinical
issue, a physician in the same or similar specialty as
the treatment under review, not part of the original
denial decision, will review the request. This request
should be in writing and addressed to the Member

www.carefirst.com 24
Your Coverage
Frequently Asked Questions
or individual beneﬁts under certain conditions.
A conversion policy is a contract that provides
Ending Your Coverage individual or family medical coverage. Dental, vision,
Your coverage or your dependent’s and prescription plans cannot be added to the
coverage with CareFirst BlueChoice may conversion policy.
automatically end for certain reasons. These
reasons may include but are not limited to:
Eligible members must enroll for conversion
■ you are no longer employed by the coverage within 31 days after their eligibility
company that carries your CareFirst for group coverage ends. Members who
BlueChoice coverage; end or lose their group coverage may
be entitled to a conversion policy in the
■ your employer cancels coverage following situations:
with CareFirst BlueChoice;
■ the policyholder’s eligibility for his or
■ divorce from a policyholder; or her current group coverage ends;

■ a dependent child marries, is no longer a ■ termination of spouse’s and dependents’
full-time student or has a birthday placing eligibility due to the policyholder’s death;
him or her beyond the age of coverage.
■ termination of marriage to the
Please refer to your Evidence of Coverage or policyholder;
contact Member Services for more
information. ■ termination of the group agreement if
the group has not provided for continued
coverage through another plan, and
Continuing Your Coverage termination is not a result of the group’s
If you are changing jobs or your dependents’ status failure to pay premiums; or
changes, please speak to your employer, your payroll
■ termination of dependent’s eligibility
ofﬁce or Member Services about the options available
due to reaching the age limit or marriage.
to you and your eligible dependents to continue health
care beneﬁts.
If you are interested in receiving a conversion policy
If you have group coverage, you and your dependents application, please contact Member Services at the
may be eligible under federal laws to continue your phone number listed on your member ID card.
coverage with CareFirst BlueChoice at your own
expense under the Consolidated Omnibus Budget New Technology Assessment
Reconciliation Act of 1985 (COBRA). Your former To ensure that our members have access to safe
employer is responsible for supplying eligible and effective care, CareFirst BlueChoice has a formal
beneﬁciaries with the details about COBRA coverage. process to review and make decisions regarding new
You and your dependents may be eligible for developments in medical technology. We evaluate
continuation under a state or federal district provision. new medical technologies and the use of existing
See your Evidence of Coverage for more information. technologies through a formal review process.
Another option may be a CareFirst BlueChoice We refer to medical personnel, governmental
conversion policy. A conversion policy is a non-group agencies and published articles about scientiﬁc
policy offered to members who are losing their group studies in this process.

25 FirstHelp ® Health Care Advice Line: (800) 535-9700
Portability (HIPAA)
Frequently Asked Questions
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) ensures that individuals who
have health insurance do not experience a gap in
coverage due to termination or departure from their
current job. A member terminating coverage with an
insurance carrier will receive a Certiﬁcate of Creditable
Coverage indicating the length of time they have
had health insurance coverage. This Certiﬁcate of
Creditable Coverage is used to reduce any waiting
time for pre-existing conditions that may be part
of subsequent health insurance coverage, as long
as there has not been a break in coverage for more
than 63 days.

When a member terminates with CareFirst
BlueChoice, they receive a Certiﬁcate of Health Plan
Coverage that indicates how long the member was
covered. The member should then present the
certiﬁcate to the new insurance carrier. This will
reduce or eliminate waiting periods for pre-existing
conditions under the member’s new policy.

www.carefirst.com 26
Frequently Asked Questions
Conﬁdentiality
All health plans and providers must provide To obtain a copy of our Notice of Privacy Practices,
information to members and patients regarding please visit our web site at www.careﬁrst.com or call
how their information is protected. You will receive a Member Services at the telephone number on your
notice of privacy practices from CareFirst BlueChoice member ID card.
or your Health Plan, and from your providers as well,
when you visit their ofﬁce. Members of self-insured groups should contact their
Human Resources department for a copy of their
CareFirst BlueChoice has policies and procedures Notice of Privacy Practices. If you don’t know whether
in place to protect the conﬁdentiality of member your employer is self-insured, please contact your
information. Your conﬁdential information includes Human Resources department.
Protected Health Information (PHI) and other
nonpublic ﬁnancial information. Because we are
responsible for your insurance coverage, making sure Your Rights
your claims are paid, and that you can obtain any You have the following rights regarding your
important services related to your health care, we own Protected Health Information. You have
are permitted to use and disclose (give out) your the right to:
information. Sometimes we are even required by law
to disclose your information in certain situations. You ■ request that we restrict the PHI we use or
also have certain rights to your own protected health disclose about you for payment or health
information, and there are some requirements you will care operations;
have to follow to allow other people to obtain your
information on your behalf. ■ request that we communicate with you
regarding your information in an alternative
Our Responsibilities manner or at an alternative location if you
We are required by law to maintain the privacy of your believe that a disclosure of all or part of your
PHI, and to have appropriate procedures in place to PHI may endanger you;
do so. In accordance with the federal and state Privacy
laws, we have the right to use and disclose your PHI ■ inspect and copy your PHI that is contained
for payment activities and health care operations as in a designated record set including your
explained in the Notice of Privacy Practices. This medical record;
Notice is sent to all policyholders upon enrollment.
■ request that we amend your information
Notice of Privacy Practices if you believe that your PHI is incorrect
or incomplete;
CareFirst BlueChoice is committed to keeping the
conﬁdential information of members private. Under ■ an accounting of certain disclosures of
the Health Insurance Portability and Accountability your PHI that are for reasons other than
Act of 1996 (HIPAA), we are required to send our treatment, payment, or health care
Notice of Privacy Practices to members of fully operations; and
insured groups only. The notice outlines the uses
and disclosures of protected health information, ■ give us written authorization to use your
the individual’s rights and CareFirst BlueChoice’s protected health information or disclose
responsibility for protecting the member’s it to anyone not listed in this notice.
health information.

27 FirstHelp ® Health Care Advice Line: (800) 535-9700
Frequently Asked Questions
Member Rights and Responsibilities
Rights of Members Responsibilities of Members
The Plan promotes members’ rights Members have a responsibility to:
by providing mechanisms to ensure: ■ Provide, to the extent possible, information
that the Health Plan and its practitioners
■ Protection of conﬁdential information.
and providers need in order to care
■ Accurate and understandable information for them.
about beneﬁt plans, customer service and
■ Understand their health problems
accessing health care services.
and participate in developing mutually
■ Continuity and coordination of agreed upon treatment goals to the
medical and/or behavioral health degree possible.
or substance abuse care by
■ Follow the plans and instructions for
participating providers.
care that they have agreed on with their
■ Professional and responsive practitioners.
customer service.
■ Pay copayments or coinsurance at the time
■ Timely and complete resolution of service.
of customer complaints and appeals.
■ Be on time for appointments and to
Members have a right to: notify practitioners/providers when an
appointment must be canceled.
■ Be treated with respect and recognition
of their dignity and right to privacy.

■ Receive information about the Health Plan,
its services, its practitioners and providers,
and members’ rights and responsibilities.

■ Participate with practitioners in decision
making regarding their health care.

■ Participate in a candid discussion of
appropriate or medically necessary
treatment options for their conditions,
regardless of cost or beneﬁt coverage.

■ Make recommendations regarding
the organization’s members’ rights
and responsibilities.

■ Voice complaints or appeals about the
Health Plan or the care provided.

www.carefirst.com 28
Deﬁnition of Terms
Allowed Beneﬁt: The maximum dollar amount Covered Expenses: Amounts that are eligible for
allowed for services covered, regardless of the beneﬁts by CareFirst BlueChoice, as described in
provider’s actual charge. A provider who participates your Evidence of Coverage.
in the network cannot charge the member more than
this amount for any covered service. Covered Provider: A type of provider from whom you
are eligible to receive care under the beneﬁts described
Appeal: A protest ﬁled by a member or a health care in your Evidence of Coverage.
provider under CareFirst BlueCross BlueShield/
CareFirst BlueChoice’s internal appeal process Deductible: The dollar amount of incurred covered
regarding a coverage decision. expenses that the member must pay before CareFirst
BlueChoice makes payment.
Authorization: The contractual requirement that the
provider or member notify and obtain approval from Dependent: A member who is covered under the Plan
the plan before certain services are covered for a as the spouse or eligible child of a Subscriber.
member. Authorization is required for services such
as, but not limited to, non-emergency hospitalizations, Evidence of Coverage: A document reﬂecting an
certain outpatient hospital services, skilled nursing individual’s or group’s enrollment agreement with
care, home health care, outpatient surgical services, CareFirst BlueChoice.
and durable medical equipment.
Exclusions: Speciﬁc conditions, treatments, services or
Claim Form: A form obtained from Member circumstances listed in the contract for which CareFirst
Services for reimbursement of covered services paid BlueChoice will not provide beneﬁts.
by the member.
Health Care Provider: An individual who is licensed
Coinsurance: A percentage of the plan allowance that or otherwise authorized in this State to provide health
the member pays for a covered service (e.g., 20 percent care services in the ordinary course of business or
for lab services or x-rays). practice of a profession, and is a treating provider of
the member; or a hospital.
Complaint: A protest ﬁled with the regulatory
department involving an adverse decision, coverage Health Maintenance Organization (HMO): An
decision, appeal decision, or grievance decision. organization that provides a wide range of health
care services through a PCP who renders or
Coordination of Beneﬁts (COB): A provision which coordinates all of your care to provide you with
determines the order of beneﬁt determination when quality service while reducing medical costs.
a member has health care coverage under more than
one plan. HIPAA: Health Insurance Portability and
Accountability Act. This Act addresses many tenets
Copayment: A speciﬁed amount that the member of health insurance coverage including the handling
pays for a covered beneﬁt (e.g., $10 per ofﬁce visit of Personal Health Information (PHI) and the
to a primary care physician). Member’s ability to receive credit towards his or her
waiting period.

29 FirstHelp ® Health Care Advice Line: (800) 535-9700
Deﬁnition of Terms

Indemnity: Traditional insurance plans under which Blue Shield plan) to render covered services to eligible
the health plan reimburses the provider and the members in accordance with the terms and conditions
member on a fee-for-service basis after the patient of the Preferred Provider Plan.
has satisﬁed any applicable deductible. These plans
typically have the highest out-of-pocket expenses, Preventive Health Care: Care provided to prevent
but they give you the ﬂexibility to seek treatment disease or its consequences. It includes programs
from any covered provider. aimed at warding off illnesses (e.g., immunizations),
early detection of disease and inhibiting further
Member: An individual who meets all applicable deterioration of the body. This includes the
eligibility requirements stated in Part 2 of the Evidence promotion of health through altering behavior,
of Coverage, is enrolled for coverage, and for whom we especially by health education.
receive the premiums and other required payments. A
member can be either a subscriber or a dependent. Primary Care Physician: The Plan physician selected
by or on behalf of, the member to provide primary
Network: A group of multi-specialty medical groups care to the member and to coordinate and arrange
and individual practice doctors who are contracted to other required services.
provide services to members of a health plan.
Provider: An individual, institution or organization
Participating Provider: A covered provider that that provides medical services. Examples of
contracts with CareFirst BlueCross BlueShield/ providers include physicians, therapists, hospitals
CareFirst BlueChoice to be paid directly for rendering and home health agencies.
covered services to eligible members of this plan.
Referral: A written authorization by the PCP for the
Practitioner: Professionals who provide health care member to see a specialty provider.
services. Practitioners are required to be licensed as
deﬁned by law. Specialist: A licensed health care provider to whom
a member can be referred to by a PCP.
Preferred Provider: A covered practitioner or facility
that contracts with CareFirst BlueCross BlueShield/ Subscriber: A member who is covered under the
CareFirst BlueChoice (or with another Blue Cross and Plan as an eligible employee or member of the group,
rather than as a dependent.

www.carefirst.com 30
Index
Alternative therapies (Options) 12-14 Hospital care, continued stay review 11
Appeals 24 Laboratory services 7
Appointments, canceling 7 Medical emergency, deﬁnition 15
Appointments, making 6 Medical records 6
Appointments, scheduling guidelines 6 Medical records, conﬁdentiality 6, 27
Argus Health Systems 20 Member satisfaction 23-24
Away From Home Care® 17 Member ID card 1
BlueCard® Program 16 Mental health care 17
BlueVision 21 My Care First 8
CareEssentials 8-11 My Account 4
Case Management Program 11 Options Discount Program 12-14
Claim forms 22 Other insurance 22
College students 17 Portability (HIPAA) 26
Complaints 23-24 Prescription drugs 19-20
Conﬁdentiality 27 Prescriptions, drug formulary 20
Contact lenses 21 Preventive services guidelines 9
Coordination of beneﬁts 22 Primary care physician, changing 6
Corrective lenses 21 Primary care physician, choosing 5
Coverage, continuing 25 Primary care physician, role of 5
Coverage, ending 25 Prior authorization 20
Denial of beneﬁts, appeals 23-24 Provider directory 2, 4
Dental care 19 Referrals 6
Disease management programs 11 Reimbursement, how to ﬁle a claim for 22
Emergency, deﬁnition 15 Responsibilities, member 28
Evidence of Coverage 29 Rights, member 28
FirstHelp® 16 Specialists 2, 6
Follow-Up Care 17 Substance abuse 17
Frequently asked questions 2-4 Traveling, care while 16
Great Beginnings Program for Expectant Mothers 8 Urgent care centers 15
Gynecological care 9 Utilization Management 10
Hospital care, authorization for 10 Vitality member newsletter 8

31 FirstHelp ® Health Care Advice Line: (800) 535-9700
For More Information, Call Member Services at the Telephone Number on Your Member ID Card.

Policy Form Numbers

DC:
Prescription Drug Rider: DC/CC/Ind Drug (11/04)

MD:
and any amendments or riders. Prescription Drug Rider: MD/CC/Ind Drug (R. 10/04)

MSGR:

VA:
Prescription Drug Rider: None

Dental Policy Form Numbers

DC:

MD:

VA:

Vision Policy Form Numbers

DC:
CFBC/EXCLUSION-V (9/04)

MD:

VA:

10455 Mill Run Circle
Owings Mills, MD 21117
www.careﬁrst.com
CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

VA FORM #: BOK5075-1S (12/09) web only